Questions related to the case summary

• What is criteria?

• Vertical integration vs. horizontal integration

Principles of Medicare• Public administration

• Comprehensiveness

• Universality

• Accessibility

• portability

Our health care system defines us as communities,as a society, and as a nation. What Canadians areprepared to do, and more importantly, what we

arenot prepared to do for each other when we are

sick,vulnerable, and most in need, says a great deal

aboutCanada, our basic values, and the values that wewant to hand on to future generations of

Canadians.Margaret Somerville, LLB

Founding Director, The McGill Center for Medicine, Ethics and Law

McGill University, Montreal, Quebec

• 95% hospitals are non-profit entities– Run by community boards of trustees,

voluntary organizations or municipalities.– Accountable to the communities they serve, not

to the provincial bureaucracy

• Rely extensively on primary care physicians– Account for 51% of all active physicians in

Canada– Paid on fee-for-services basis– Act as “gatekeeper” of the Canadian health care

system

                                   

                 

                 

                 

                 

                 

                 

                 

                 

                 

                 

                                                                                                                                                     

                      

                  

                

               

                                                                          

                                                                          

Objectives

• Understand the context of the reform of the Canadian health care system

• Analyze the causes of the problems in the Canadian health care system

• Identify possible solutions

Current problems of the Canadian health care system

• Emergency overcrowding• Doctor shortage

– One in four Ontario doctors will retire in four years

– By 2020, 30% of Ontario’s population will be over the age of 55.

• Waiting time– Access to health care providers, diagnostic tests,

specialty treatment, hospital beds

• Waiting time examples:– Six months to obtain a hip replacement

– Five months to get a CAT scan

– Some patients wait more than a year for cardiac surgery

– Some cancer patients go to the States for treatment

– 2/3 Canadian physicians are finding it difficult to get appropriate resources such as diagnostic tests, referrals or operating room time for their patients.

The current situation• Aging population (30% of Ontario

population over 55)

• Physicians shortage

• family physicians have heavy work loads

• Funding constraints

Projecting the future health careOld NewAcute care continuum of careTreating illness maintaining and promoting

wellnessIndividual patients defined populationProvider similar differentiationInpatient admission people healthFill beds provide timely careSeparate org. Integrated systemRun organization oversee a marketManagers as depart.heads operate across organizationsCoordinate services pursue quality improvement

Causes

• Less funding for hospitals, resulting in– Lay off employees (e.g., nurses)– over-crowdedness– Longer waiting time– Decreasing quality of the health care

Causes (contd.)• Payment system (how patients pay for the health

care services and how physicians get paid)– Physicians

• Focus on volume, thus longer waiting time

• Reluctant to refer to specialists

• Duplicated services

– Patients • Don’t care about costs

• Solely rely on physicians

• Lack of knowledge on the common diseases

Causes (contd.)

• Structure – Task-oriented rather than customer-oriented

• Patients on their own• Long waiting time• Difficult to give the right care to patients at the right

place and right time

– Lack of integration among sectors• Duplicated services• Quality of care

Causes (contd.)

• Structure – Physician as “gatekeeper”

• Shortage of doctors becomes a bottleneck

• Longer waiting time for specialists

• Heavier work load

Causes (contd.)

• Philosophy – Cure disease rather than prevention and

promotion– Patient rather than customer

Criteria

• Reduce costs

• Reduce physicians’ work loads

• Enhance the quality of the health care

• Not violate five principles

• Stakeholders are willing to accept

• Shift to prevention

PerspectivesQuality in health care can be reflected through theperspectives of its different stakeholders: the patient(client, resident), the provider, the funder, and society.From the patients’ perspective, quality is defined interms of how well their needs and expectations for careand service are met. For the providers, quality includesclinical effectiveness in terms of the correctness of thediagnosis and the appropriateness and efficacy ofthe treatment and care provided. From the system'sperspective, quality is concerned with the efficiency ofthe services provided and the cost effectiveness,management and use of resources to achieve desiredhealth outcomes. Finally, to society, quality is oftenmeasured in terms of value for money and benefits tothe community at large.

What does quality mean?In general, quality reflects the extent to which healthservices meet the specified goals and standards of theaccepted norm for good care and health service. Qualityin health care is judged by three key areas, namelystructure, process, and outcomes. Structure

comprisesthe necessary resources to conduct the task (e.g. theresources to deliver the care, the physical resources,facilities, organization, standards, policies). Process isthe act of doing the task (inputs-tasks-outputs, i.e. thecare itself), and outcomes are the result (e.g. effectivecare, patient satisfaction, efficient use of resources).

• The enhanced continuity of care

• A stepped up focus on prevention and healthy living

• 24-hour access to health advice through a dedicated telephone helpline

• Improved communication though increased use of information technology

Solution of Dr. Jim MacLean

IHS

• Fully connected through the use of information and communication technologies that use universal standards for shared information systems – a system that is fully connected.

What are the current situation?

• There are 57,243 practicing physicians in Canada– 19,398 in solo practice– 35,658 in group practice in 17,829 group

offices– 1,997 teaching or in administrative positions

• There are about 229,813 nurses

• About 18,300 community and 4,000 hospital pharmacists and 7000 pharmacies

• 845 hospitals

• 6,129 long-term care institutions

• 1,798 labs

• 2,660 imaging locations

• Fewer than 5% of physician’s offices have Internet-capable PCs.

What are the challenges?

• Funding required– Total initial start-up cost $ 4.1 billion– After implementation, operating costs $830

million

What have been done so far?

Primary care reform• Physicians

– High level of satisfaction except those in Chatman – No change in their practice patterns– Some found unable to offset the extra costs of

information technology– Found difficult in providing on-all coverage (since they

can’t bill for the telephone advice)– Unrealistic expectations from the government– Information technology acquisition process (lengthy,

resource-intensive, inefficient, and fragmented)

Final thought

If survival of the Canadian Healthcare System isdesired by Canadians it must be managed differentlythan in the past. Continuous Quality improvementis a management philosophy that offers promise tosave our system through the reduction ofinefficiencies and inappropriate variation asidentified by line healthcare professionals andsupport staff. The spark and direction to begin theimplementation of Continuous QualityImprovement must come from medical, nursing andadministrative leaders who will be required to set thestage, create the culture and provide a vision of apreferred future.

R.H. Wensel, MD, FRCP(C)Health Care Consultant

Edmonton, Alberta